Failure to Follow Hand Hygiene and PPE Protocol During IV Infusion
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper hand hygiene and personal protective equipment (PPE) protocols while assisting a resident with an intravenous (IV) infusion. The resident, who had a midline catheter for anemia treatment and multiple diagnoses including metabolic encephalopathy, type 2 diabetes, stroke, and weakness, was observed during the setup of an iron infusion. The LPN exited the resident's room wearing gloves, used scissors from the medication cart to open an IV-line package outside the room, and then reentered the room still wearing the same gloves. Inside, the LPN continued to handle the IV line and moved a trash can without changing gloves or performing hand hygiene. The LPN later confirmed that she did not remove her gloves or perform hand hygiene when leaving and reentering the resident's room, acknowledging that this was a violation of infection control protocol. The Director of Nursing (DON) stated that staff are expected to remove gloves and perform hand hygiene before exiting a resident's room. Facility records indicated that all staff receive infection control and hand hygiene education upon hire and annually.